Healthcare Provider Details

I. General information

NPI: 1174568240
Provider Name (Legal Business Name): PHARMACY MANAGEMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL RD BLDG 3 PROFESSIONAL PLAZA
STARKVILLE MS
39759
US

IV. Provider business mailing address

101 12TH ST S
COLUMBUS MS
39701-5830
US

V. Phone/Fax

Practice location:
  • Phone: 662-323-0885
  • Fax: 662-323-7298
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number07472
License Number StateMS

VIII. Authorized Official

Name: RON HARRIS
Title or Position: CEO MANG MEMBER
Credential:
Phone: 662-327-4025